Anorectal fistula


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Anorectal fistula

  1. 1. Dr.Vidya
  2. 2.  FISTULA - Abnormal connection b/w two epithelium lined organs or vessels. It is generally a disease condition. It may be surgically created for therapeutic reasons.  ANORECTAL FISTULA - Abnormal connection b/w epithelialised surface of anal canal & the Perianal skin.  Internal opening- Anorectal lumen  External opening- Perianal skin  Pre-existing anorectal abscess burst spontaneously .  Other: rectovesicular, rectovaginal, rectourethral fistula.
  3. 3. Etiology  Non specific - cryptoglandular in origin  Specific : - Crohn’s disease - tuberculosis - lymphogranuloma venereum - actinomycosis - rectal duplication - foreign body - malignancy
  4. 4. Anatomy – Muscles  Internal sphincter  External sphincter  Intersphincteric groove  Puborectalis (Levator ani)
  5. 5. Park’s Classification of Anorectal Fistulas  Type 1 - Intersphincteric (45%)  Type 2 -Transphincteric  Type 3 – Suprasphincteric  Type 4 - Extrasphincteric
  6. 6.  Intersphincteric – through the dentate line to anal verge, tracking along the intersphincteric plane, ending in the perianal skin.  Transsphinteric – through the external sphincter into the ischiorectal fossa, encompassing a portion of internal & external sphincter ending in the skin.  Suprasphinteric – through the anal crypt & encircling the entire sphincter ending in ischiorectal fossa.  Extrasphinteric – starting high in the anal canal, enclosing the entire anal sphincter & ending in the skin.
  7. 7. Park’s Classification of Anorectal Fistulas
  8. 8. Clinical Presentation  H/o  Chronic drainage from “nonhealing abscess”  Pain with defecation  Pruritus ani  Systemic symptoms if abscess gets infected.  Physical exam  Draining pustule  Erythema, induration, excoriated skin
  9. 9. Goodsall’s Rule  Goodsall’s rule is a guideline for internal opening & path of fistula track & aids in Rx.  Fistula can be described as anterior or posterior relating to a line drawn in the coronal plane through ischial spines across the anus - called transverse anal line.  Anterior fistulas - have a direct track into the anal canal.  Posterior fistulas - have a curved track with their internal opening lying in the posterior midline of the anal canal.  An exception to the rule - anterior fistulas lying more than 3 cm. from the anus, which may have a curved track (similar to posterior fistulas) that opens into the posterior midline of the anal canal.
  10. 10.  Goodsall's rule may not be applicable when the fistula is more than 3 cm from the anal verge, as mostly these fistula are indirect.  If there are multiple anal fistulae, the course would be similar to that of posterior-opening fistulae because of branching and communication between these openings
  11. 11. Diagnosis • Exam under anesthesia (EUA)- anoscopy, proctoscopy; assess for internal opening and occult abscess – Injection of Hydrogen peroxide or povidone iodine allows to visualize bubbles at internal opening(s) • Endo anal ultrasound • MRI – gold std • Fistulography • CT
  12. 12. Management  Goals of Therapy  Drain local infection  Eradicate fistulous tract  Avoid recurrence while preserving native sphincter function  Surgical management  Fistulotomy  Fistulectomy  Seton technique  Advancement flaps & glues  LIFT procedure
  13. 13. Fistulotomy  lay open fistula tract, make incision over entire length of fistula using probe as guide  intersphincteric fistula & trans-sphincteric fistulae involving less than 30% of the voluntary musculature .  Avoided for anteriorly placed fistulae in women  Staged Fistulotomy – seton passed across the fistula & left in place with tie  Fistula granulates & heals from above to close completely.
  14. 14. Fistulotomy
  15. 15. Cutting Seton (Staged Fistulotomy)
  16. 16. Fistulectomy  involves coring out of the fistula by diathermy cautery  Better for fistula that cross level of sphincters and the presence of secondary extensions.  Post-op: sitz bath, antibiotics, analgesics, laxatives
  17. 17. Setons  non-absorbable, nondegenerative, comfortable.  Silk or linen ligature  m/c intersphincteric fistula.  Kept for 3 months replaced by rail road tecq.  loose setons: no tension, no intent to cut the tissue. - for recurrent, post operative fistulas.  Uses of loose setons. - For long-term palliation to avoid septic and painful exacerbations by effective drainage - before ‘advanced’ techniques (fistulectomy, advancement flap, cutting seton) - staged fistulotomy - preserve the external sphincter in trans-sphincteric fistulae.
  18. 18. Tight or cutting setons :  placed with the intention of cutting through the enclosed muscle.  Used if the fistula is in a high position and it passes through a significant portion of the sphincter muscle  high fistula eradication rates a/w fistulotomy.  Minimising sphincter dysfunction due to least scar formation.  cheese wiring through ice -such that the divided muscles do not spring apart.  site of the fistula track is replaced by a thin line of fibrosis as it is brought down.
  19. 19. Advancement flaps  Endorectal advancement flaps:-coring out of the entire track; and closure of the communication with the anal lumen with an adequately vascularised flap consisting of mucosa and internal sphincter, sutured without tension to the anoderm.  Success rate is variable.  high recurrence rates are directly related to previous attempts to correct the fistula.
  20. 20. Mucosal advancement flap
  21. 21. Fibrin plugs & Glues : Fibrin plug-  Plugging the fistula with a device made from small intestinal submucosa.  The fistula plug is positioned from the inside of the anus with suture.  Success rate with this method is as high as 80%.  Fistula plug procedure requires hospitalization for only about 24 hours.
  22. 22. Fibrin plugs
  23. 23. •Fibrin glue: - Fibrin glue is currently the only non-surgical option for treating fistulae. - The fibrin glue is injected into the fistula to seal the tract. The glue is injected through the opening of the fistula, and the opening is then stitched closed. -long-term results for this treatment method are poor.
  24. 24. LIFT Procedure  Ligation of intersphinteric fistula tract procedure.  Based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach.  Essential steps -  incision at the intersphincteric groove  identification of the intersphincteric tract ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract  scraping out all granulation tissue in the rest of the fistulous tract suturing of the defect at the external sphincter muscle
  25. 25. Differential diagnosis  Anal carcinoma  Anorectal abscess  Constipation  Diverticular Disease  Foreign Bodies, Rectum  Herpes Simplex  Inflammatory Bowel Disease  Pilonidal Cyst and Sinus  Proctitis
  26. 26. Thank you